Category Archives: Trans kids and teens

This is a case study of a trans man (born female) with many serious mental health problems, including an eating disorder. He was a survivor of childhood sexual abuse and the trauma seems to have been at the root of his problems.

This case study does not make any connections between his eating disorder and his gender dypshoria. Given the abuse and the multiple comorbidities, it is unlikely that the gender dysphoria caused the eating disorders.

The authors suggest that both the eating disorder and the gender dysphoria were caused by the early trauma.

“the underlying foundation of these multiple diagnoses is the presence of early developmental trauma to the emotion regulation system — which manifests as physical and emotional pain with impulsive and maladaptive attempts to engage in behaviors to meet personal needs, including safety. Zanarini and colleagues performed a study examining Axis I comorbidity in patients with BPD [borderline personality disorder] and identified high rates of comorbid PTSD. They also observed that meeting criteria for multiple Axis I disorders predicted meeting criteria for BPD.”

Medical transition came later and was not part of the recovery from the eating disorder. However, at the time the patient entered therapy, he had already taken a male name and was dressing and living as a male.

This case study has some similarities to the case of a teenage girl* who developed gender dysphoria while being treated for an eating disorder. The teenage girl was also a survivor of childhood sexual abuse with multiple mental health problems: anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). In addition, she had a past history of PTSD, OCD, self-harm, and suicidal thoughts.

These two cases suggest that in some cases, gender dysphoria is not the main cause of an eating disorder. Rather, trauma causes multiple mental health issues.

There are two more case studies of transgender people with eating disorders who were survivors of child abuse. They suggest different possible conclusions, however.

A trans woman whose eating disorder began when she started to live as a woman. Her goal was to have a more feminine shape. Transition and hormones did not cure the eating disorder, however. She had been physically and sexually abused as a child.

A trans woman whose identical twin also had an eating disorder. Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both survived an abusive father who threatened them with assault and death. However, one was a trans woman and one was a gay man.

In the first case, the eating disorder seems to be closely connected to the gender dysphoria since it started when she began to live as a woman. She clearly describes wanting to look more female. The abuse may have affected her, but gender dysphoria was also a factor.

In the second case, the eating disorder seems to have been caused by a combination of genes and environment, since both twins had anorexia but only one had gender dysphoria.

We’re left with the possibility that the answer is different in different cases. Sometimes severe childhood trauma may cause multiple mental health problems that include an eating disorder. Sometimes a combination of gender dysphoria and early childhood trauma may contribute to an eating disorder. And sometimes the same genes and environment will produce two people with similar eating disorders but different gender identities.

Of course, these are only four case studies. We can’t draw conclusions from them about all transgender people with eating disorders. Most of the case histories I have found don’t mention child abuse. Many of them suggest connections between gender dysphoria and eating disorders.

What we can see from these cases, however, is that for some transgender people with eating disorders, gender dysphoria is not the main or only cause of their eating disorder. Therapists should keep this in mind when treating transgender patients for eating disorders.

The article provides an interesting discussion of diagnosing and treating a patient. The full text is available online without cost, but here are a few details of the case:

The trauma the trans man survived involved “repeated episodes of sexual violence perpetrated from age 4 to 9 years old by a childhood friend’s father in the neighborhood.”

…

“The patient believed he had suffered multiple head injuries related to physical violence and asphyxiation in the context of sexual trauma, but was unclear if he had lost consciousness because of head injury or because of psychological dissociation during these events.”

…

He had “a history of heavy chemical use, starting with first use of alcohol at age 7, which continued through age 23. He also used diet pills starting at age 14, followed by heavy use of cannabis at age 15, and cocaine and other narcotics, including pills and heroin, at age 18 years.”

…

The patient had severe pelvic floor dysfunction which caused him a great deal of pain. It took him a while to get this diagnosed correctly.

…

“The patient was born and raised as a female, but in retrospect realized he did not fully identify with either the male or female gender. In the previous 2 years, he had decided to openly adopt a male gender, name, and manner of dress. He had the intention of pursuing hormone therapy and, eventually, chest reconstruction.”

…

Treatment and afterwards:

“Suicidal thoughts and behaviors were identified as the highest-priority target; after 6 months, these thoughts and behaviors had resolved. The patient was engaged in therapy and did not require significant emphasis on therapy interfering behaviors; therefore, quality-of-life interfering behaviors could be targeted, including purging behaviors, urges to use substances, self-injury, self-care, and interpersonally effective behaviors with friends, family, and other medical professionals. He graduated phase 1 of DBT therapy and proceeded to phase 2 to continue working on healthy emotional experiencing and management of trauma sequelae.

The patient graduated college with a high grade point average and went on to pursue master’s level education. He underwent sex hormone treatment and chest reconstruction.

He developed additional medical comorbidities, including insulin resistance and adrenal insufficiency. These medical conditions necessitated moving back in with his parents, resulting in significant familial conflict. The patient’s therapist made a referral for family therapy through our department, which was coordinated among treatment providers. The patient is enthusiastic about the progress made in treatment and states he often wonders if he would be still be alive without the intervention he received. Over the course of 3 years, his medications were all tapered to discontinuation, with the exception of prazocin 10 mg at bedtime for nightmares, ramelteon 8 mg for sleep, and clonazepam 1 mg three times a day, which was continued to assist with pelvic musculature functioning.”

This is a fascinating study of identical twins; one had gender dysphoria and one did not. Both twins developed anorexia.

Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both had a difficult childhood with an abusive father.

Both twins were underweight at birth and needed intensive care. Both had developmental delays.

However, one twin considered himself to be a gay man while one identified as a straight woman.

In this case study, gender dysphoria did not cause the eating disorder.

This case highlights the importance of other factors in eating disorders, including genes, hormones, and trauma.

It raises the question; how important is gender identity as a cause of eating disorders?

This case is different from other case studies where gender dysphoria seems to be intimately linked to the eating disorder.

We can’t look at these two patients and conclude that gender dysphoria never contributes to eating disorders. However, this case is a good reminder to be cautious about drawing conclusions from other case studies. Perhaps there are just some people with eating disorders who also have gender dysphoria. Or perhaps there is some other factor which causes both eating disorders and gender dysphoria.

As always, we need more studies.

More about the Patients:

Eating Disorders

Twin A was diagnosed with AN-purging subtype and Twin B was diagnosed with AN-restricting subtype.

Twin B developed an eating disorder at an earlier age, but Twin A was more underweight and had a more disturbed perception of his body. Furthermore, Twin A was hospitalized for his eating disorder and Twin B was not.

Neither twin seems to have been able to maintain a healthy weight.

At age 16 Twin A“was admitted to a children’s hospital because of AN. Later, he was hospitalized in the psychiatric inpatient unit for adolescents. At first, his eating behavior was restrictive. Then he reported intermittent vomiting (AN binge-purge). His weight decreased to 46 kg/1.79 m (body mass index [BMI] ¼ 14.3 kg/m²). His ideal weight was 44 kg according to a BMI of 13.7 kg/m² , which shows his severe disturbance in body perception. During hospitalization, his behavior was sometimes aggressive. He was emotionally unstable, depressed, and was rarely able to engage in stable relationships. Despite strict dietary rules, he achieved a maximal weight of 55 kg (BMI ¼ 17.2 kg/m²). Soon after being discharged, his weight decreased again.”

Twin B’s eating disorder began at a younger age. “In puberty, he developed severe underweight. At the age of 13, he was 42 kg/1.58 m (BMI ¼ 16.8 kg/m² ). When he was referred to our outpatient unit at the age of 18½ years [for gender dysphoria], his weight was 48 kg and his height was 1.76 m (BMI ¼ 15.5 kg/m² ). He denied deliberate dieting, binging, or purging. Although he regarded himself as too slim, he did not manage to gain weight. Further medical checkups revealed no somatic cause for his underweight. An osteodensitometry yielded an osteopenia of the spine.”

Gender Identity

Twin A was a gender non-conforming gay male:

“In childhood, he preferred girls’ games and toys (Barbie dolls) and was very close to his twin brother. His sexual feelings were always for males. Although he started cross-dressing at the age of about 16 years, his gender identification was always male. He considered himself to be a homosexual.”

Twin B was a trans woman:

“As far as he could remember, he had felt he was a girl, preferring girls as playmates and had started cross-dressing at nursery school. In gymnastic lessons, he refused to change with the other boys because he was ashamed of his body. Eventually, he refused to attend sports lessons at all. When he was 9 years old, he started to grow his hair. His class mates seemed to accept him as a girl. When he started to work as a hairdresser, he tried to correspond to the male gender role and did not cross-dress. However, at his professional school and in his free time, he continued to cross-dress. His employer, who realized he was transsexual, permitted and encouraged him to cross-dress at work, which consequently allowed him to live as a young woman. Sexually, he was always attracted to men. However, in contrast to his brother, he never considered himself to be homosexual and viewed this attraction as ‘‘heterosexual.’’ Until this point, he had not engaged in sexual relationships either with men or with women.”

Twin B requested hormonal and surgical sex reassignment.

Childhood

The twins grew up together in a small Swiss city without any other siblings. Their childhood was not easy:

“[Their father] was very authoritarian. He could not accept the sexual orientation and the cross-dressing of his sons and threatened them with assault and even with death.

…In family conflicts, [their mother] took a position between her husband and her sons. At a family consultation, she appeared emotionally unstable.”

Birth

The birth was a difficult one. Both twins were underweight and spent time in intensive care.

“the mother had been admitted to a hospital with hypertension, edema, and proteinuria at 38 weeks of gestation. The vaginal delivery was induced because of maternal preeclampsia. Twin A weighed 2.17 kg at delivery and his Apgar score was 9/9/9. Because of perinatal acidosis and hypotonia, he was kept in the incubator for 3 days. He was diagnosed with a subependymal hemorrhage with ventricular invasion. Twin B’s birth weight at delivery was 1.95 kg and his Apgar score was 7/9/9. Both twins were admitted immediately to the neonatal intensive care unit.”

Developmental Delays

They both had developmental delays:

“In early childhood, Twin A showed a developmental delay in language and motor skills and had deficits in cognitive and verbal skills. He was socially isolated and his behavior was often aggressive.”

“…Twin B had delays in language and motor development during early childhood. He showed the typical symptoms of attention deficit and hyperactivity disorder. The parents refused further assessment and treatment.”

Other

Twin A was diagnosed with borderline personality disorder and subnormal verbal intelligence.

Twin B was diagnosed with gender dysphoria.

There is no obvious pattern to any of this. Twin A was larger at birth, but had more problems right after birth. Both had developmental delays, and Twin B may have had ADHD as well. Both were feminine in their behavior, but only Twin B developed gender dysphoria. Both were sexually attracted to men. Twin B developed an eating disorder earlier, but Twin A’s eating disorder seems more severe. Twin A has borderline personality disorder and Twin B does not.

Discussion

The authors offer two possible hypotheses about the twins’ gender identity.

Perhaps the twins are on a continuum of gender non-conformity where gender dysphoria is at the extreme end.

Alternatively, perhaps gender dysphoria* in childhood is inherited, but the later development of gender identity is determined by environmental factors and psychiatric comorbidity.

“In childhood, both Twin A and Twin B showed gender atypical behavior and stereotypical feminine traits and interests. In adolescence, their sexual orientation was revealed to be homosexual. Twin A developed effeminate homosexuality with male gender identity, whereas Twin B stabilized his cross-gender identity. Although Twins A and B are concordant for GID in childhood and sexual orientation on a categorical level, they are now discordant for TS. On a more dimensional level, one could argue that Twins A and B show an opposite sex-dimorphic behavior and that they arrived at different points of a continuum. The fact that GID in childhood is a predictor for later homosexuality and TS could support the dimensional view. It could be hypothesized that GID in childhood is mainly hereditary, whereas the development of the later phenotype of the gender identification is determined by environmental factors and psychiatric comorbidity, as any difference between MZ twins provides strong evidence for the role of environmental influences.”

The authors also discuss the relationship between gender and eating disorders. However, they don’t address the fact that the two twins had different gender identities, but both had eating disorders.

Perhaps both gay men and trans women are vulnerable to eating disorders for different reasons, but perhaps genes, hormones, and environment matter more than gender identity.

“Homosexual men seem to have an increased vulnerability to eating disturbance and body dissatisfaction (Williamson & Hartley, 1998), are more dissatisfied with their weight (French, Story, Remafedi, Resnick, & Blum, 1996), and are more concerned about their attractiveness (Siever, 1994). Male AN is associated with disturbed psychosexual and gender identity development, which supports the hypothesis that males with atypical gender role behavior have an increased risk of developing an ED (Fichter & Daser, 1987). Furthermore, feminine gender traits are discussed as a specific risk factor for ED in men and women (Meyer, Blissett, & Oldfield, 2001). Although the role of sexual orientation as a risk factor for ED is well documented, there is hardly any literature about GID and ED. For men with disturbance of gender identity in addition to the aforementioned factors concerning sexual orientation, underweight could be a way to suppress their libido and the expression of their secondary sexual characteristics and, at the same time, correspond to a female ideal of attractiveness (Hepp & Milos, 2002).”

We need more research!

“Further research in eating behavior and body dissatisfaction in patients with GID could provide more insight into the role of gender identity in the development of ED and lead to a better understanding of ED as well as GID.”

* In this case, gender non-conformity might be a more fitting phrase. Twin A does not seem to have ever wanted to be a girl.

Another case where gender identity is linked to an eating disorder, this time in a trans man (born female).

And, another case where transition did not cure the eating disorder.

In this case a teenager who was being treated for his eating disorder requested therapy for gender dysphoria. His weight had already been restored, although he was still getting therapy for the eating disorder.

After counseling for gender dysphoria, the patient took testosterone and openly identified as a man. His anxiety improved, he had more friends, and he had his first girlfriend. Five months later, he had a bilateral mastectomy.

Ten months after surgery, the patient returned to the eating clinic for help. He said that his relapse began after his surgery and got worse when he returned to normal activity.

It is important to note that six months after surgery, the patient’s weight was normal and he felt better about his appearance. However, his eating patterns do not seem to have been discussed.

The patient had not continued counseling after surgery.

There are not many details on the patient’s gender dysphoria in this case study, but there does seem to be a connection between his eating disorder and his gender dysphoria. The patient “disclosed to his family that he felt like ‘a boy in a girl’s body’ and later acknowledged that his eating disorder was related to a desire to get rid of feminine features—’I dislike my curves, my breasts, my hips, my face. I wish I had more defined muscles in my arms and a more angular face.'”

It is worth noting, however, that the patient had two cousins with eating disorders. Genetics and environment were probably also factors in his eating disorder.

The authors make a number of important points about this case in their discussion.

We don’t know if medical transition helps with eating disorders.

“Studies show that medical interventions, including both hormone therapy and surgery, improve gender dysphoria. Their effects on disordered eating in patients with gender dysphoria, however, are less clear.”

On the one hand, in one qualitative study, a trans man who had had breast reduction surgery said it helped with his eating issues. In addition, another study found that patients who had had gender reassignment surgery had less body uneasiness than patients who had not or patients with eating disorders. It is not clear to me that this last study is relevant to patients with both gender dysphoria and eating disorders.

On the other hand,

“In our patient, although he experienced considerable improvement in body image, anxiety, and social functioning following treatment for gender dysphoria, he experienced a relapse in eating disorder behaviors postoperatively. Other case reports in adults describe similar relapses in disordered eating following medical treatment for gender dysphoria.* These cases suggest that, while GCS and other medical interventions often reduce psychological distress related to gender dysphoria, additional therapies may be required to ensure long-term resolution of disordered eating. Eating disorders have high rates of chronicity as well as relapse, particularly during periods of stress and life change. It is therefore crucial to engage all patients with gender dysphoria, regardless of their stage in treatment, in open conversations about eating patterns, body image, and thought processes.”

Urgent needs have to be taken care of first.

Treatment for patients with both eating disorders and gender dysphoria needs to be integrated and hierarchical; life threatening issues have top priority. In other words, you may have to eat before you can transition.

“Eating disorder treatment is complex given the combination of medical, psychological, and nutritional needs. Patients with gender dysphoria also have distinct needs related to gender incongruity. Using a hierarchical approach is one method to help focus therapy and ensure that all needs receive attention when appropriate. Life-threatening issues, such as vital sign instability from nutritional insufficiency or suicidality, should have first priority. These issues frequently require hospitalization to initiate nutritional rehabilitation and psychiatric care in a monitored environment. Following medical and psychiatric stabilization, weight restoration can often continue in the outpatient setting with multidisciplinary support from physicians, therapists, dietitians, and when possible, family members. Throughout treatment, the eating disorder team should strive to create a safe environment for the patient to explore the sources of his or her disordered eating, providing the opportunity to recognize or reveal any underlying issues. For patients with known gender dysphoria, the eating disorder team can assist by affirming the patient’s gender identity, allowing him or her to explore different options for expressing that identity, and providing resources for specialized care.”

Trans men’s eating disorders may look different from the norm.

Trans men may have different goals from other patients with eating disorders; patients with anorexia typically wish to be thin. Trans men may be trying to eliminate their period or reduce their curves as in this case and in this Turkish case study. The trans man in this study did not care about his weight, but was very dissatisfied with his body. It is important that these patients’ eating disorders not be missed because they are atypical. As the authors say,

“While the goals of weight loss in MtF patients often align with those of cisgender eating disorder patients, the goals of weight loss in FtM patients often diverge from those of cisgender patients, potentially limiting the utility of current eating disorder questionnaires in this population.”

We need to keep track of eating disorders after transition.

We can’t assume that a patient with an eating disorder will be fine after they are treated for their gender dysphoria. Treatment for the eating disorder needs to be ongoing.

“While improvement in gender dysphoria may lead to some improvement in eating pathology, many patients may benefit from additional support from an eating disorder team, as found for our patient. Further research should explore the success of different types of eating disorder treatment in adolescents with gender dysphoria before, during, and after gender dysphoria treatment.”

Not everyone needs the same treatment for gender dysphoria.

“Treatment for gender dysphoria varies from person to person. For some individuals, dysphoria can be alleviated through psychotherapy alone or combined with non-medical changes in gender expression. For many, gender dysphoria requires hormone therapy, surgery, or both. Adolescents who desire medical treatment later in life can use hormonal treatments to suppress or delay puberty. The Standards of Care of the World Professional Association for Transgender Health, however, recommends delaying suppression until the adolescent has reached at least Tanner Stage 2, so that he or she has some experience of his or her assigned sex. Hormone therapy to feminize or masculinize the body can also be started during adolescence, although this therapy should only be used in patients who demonstrate long-lasting or intense gender dysphoria, as the effects are only partially reversible. Surgery, on the other hand, may only be pursued once the patient reaches the age of majority for his or her country. For our patient, hormone therapy began at age 18 years, 10 months after expressing symptoms of gender dysphoria, and mastectomy was performed at age 19 years.”

Comparing eating disorders in transgender teens and adults

The authors also discuss the timeline of this case – i.e. gender dysphoria was diagnosed after the eating disorder. They contrast this with case reports of adults where an eating disorder developed during or after “assuming a transgender identity.” They add that “the only other case report available on adolescent patients describes a similar progression [to this study], with both patients initially presenting with AN and later expressing themselves as transgender.”

Therefore, they suggest that “disordered eating may be the presenting symptom in some adolescents with gender dysphoria, highlighting the benefit of addressing gender identity in young patients with eating disorders. Gender identity may be addressed either using an intake form or during the patient interview.” (see below)

The situation is a little more complicated. In fact, in this case study a teenager developed an eating disorder when she decided to live as a woman. In addition, this study of an adult mentions that her eating disorder began at age 15 when she decided to live as a woman.

So we have two cases of teenagers who decided to live as women and then developed eating disorders and three cases of teenagers who were diagnosed with gender dysphoria during treatment for eating disorders. We don’t have enough cases to come to any real conclusions about the development of eating disorders and gender dysphoria in teenagers.

In any case, it may be that interviewing teenagers when they enter treatment for eating disorders will not lead to a diagnosis of gender dysphoria. In this case study, one of the teenagers was clear at the beginning of treatment that he was a gay man and did not want to be a woman. His gender dysphoria developed during the treatment of his eating disorder.

As always, we need more research. So far we have case studies of 17 patients. The individual cases vary widely and it’s unclear exactly how gender dysphoria and eating disorders are linked. It does not seem that treating gender dysphoria cures eating disorders, however.

This newest case study demonstrates that transition for gender dysphoria does not cure an eating disorder. It points to a connection between the eating disorder and the desire to be a man, but it also points to a possible contribution from genetic and environmental factors.

*In this case study, one of the trans women had an eating disorder in adolescence that returned many years later after surgery. In this case study, one of the trans women had transitioned but was still severely underweight – although the authors did not seem to think she had an eating disorder. Finally, in this case study, a trans man developed an eating disorder after surgery. He had not had an eating disorder previously.

In addition, there are a number of case studies where patients had eating disorders, although they were on hormones and had socially transitioned.

More details from the case study:

The patient had been seeing doctors for a couple of years before he brought up his gender issues.

At age 16 the patient was not getting his period, but his weight was normal and he said he had no body image concerns. The doctors prescribed oral contraceptives.

“The patient returned a year later with 2.3 kg of weight loss, resulting in a body mass index (BMI) of 16.9 kg/m2 (81% expected body weight for females of the same age). CS acknowledged daily exercise and a ‘desire for a different body shape,’ with a ‘more toned and muscular’ appearance. The patient denied food restriction, purging behaviors, or body image distortion and committed to increasing caloric intake to gain weight. Gender identity was not discussed and no treatment was pursued after this visit.

Five months later, CS presented with an additional 4.5 kg weight loss, resulting in a BMI of 14.9 kg/m2 (70% expected body weight). The patient then admitted to food restriction as well as a fear of gaining weight, leading to a diagnosis of anorexia nervosa (AN). The clinician did not inquire about underlying motivations for weight loss beyond general body dissatisfaction and anxiety.

There was no significant medical, psychiatric, or surgical history at the time of diagnosis. Family history included two cousins with eating disorders (specific diagnoses unknown). Socially, the patient was a high-achieving student with few peer relationships and no high-risk behaviors.”

At this point, the patient began 9 months of outpatient family-based therapy for anorexia. Four months into this treatment, he requested therapy for gender dysphoria. “He began biweekly individual psychotherapy to explore his gender identity and cognitive behavioral therapy to address ongoing anxiety.”

Ten months later he started to take testosterone and five months after that he had surgery to remove his breasts at age 19.

Medical treatment for gender dysphoria helped the patient significantly with his anxiety. He began to live as a man, expanded his peer relationships, and had his first romantic relationship with a woman.

His weight was stable for six months after surgery and he was more satisfied with his body, but the follow-up does not seem to have included any discussion of his eating (“a detailed discussion of his eating patterns and cognitions was not documented”).

He returned to the clinic four months later to deal with restrictive eating and excessive exercise. His body weight had decreased and his BMI had dropped from 19 kg/m2 to 17.9 kg/m2. He explained that “his relapse began postoperatively due to exercise restrictions and school-related stress, with his behaviors intensifying when he returned to normal activity.”

More details on interviewing patients about gender

The authors offer these sample approaches:

Sample approach on an intake form.

Use a two-step approach to identify both assigned sex and current gender identity.

Assigned sex at birth:

What sex were you assigned at birth, on your original birth certificate? (check one)

□ Male

□ Female

Current gender identity:

How do you describe yourself? (check one)

□ Male

□ Female

□ Transgender

□ Do not identify as male, female, or transgender

Sample approach in an interview.

Frame discussion with an opening statement.

“Because many people are affected by gender issues, I ask all patients if they have any concerns in this area. As with the rest of the visit, what you say will be kept strictly confidential.”

Begin discussion with a broad question(s).

“What questions or concerns do you have about gender, sexuality, or sexual orientation (who you are attracted to)?”

“How do you define your gender?”

“Have you been exploring gender?”

Sample intake form from:

Reisner SL, Conron KJ, Tardiff LA, Jarvi S, Gordon AR, Austin SB.Monitoring the health of transgender and other gender minority populations: Validity of natal sex and gender identity survey items in a U.S. national cohort of young adults. BMC Public Health2014; 14:1224.

This is the earliest (1997) case study of someone with both gender dysphoria and an eating disorder.

Eating disorders are rare in children and in males, so an eating disorder in a boy is very unusual.

The boy’s mother had “abnormal eating habits and attitudes” and had been diagnosed with anorexia while she was pregnant with him. The boy had always been small for his age and did not get enough calories due to “extreme faddiness [picky eating] and the failure of the family to eat regular meals.” He was diagnosed with gender identity disorder when he was ten.

The boy developed a severe eating disorder at age 12 after a doctor suggested that he be given hormones to induce puberty.

In his case it looks like his gender dypshoria triggered his eating disorder, but he probably had a predisposition to problems with eating.

Treatment focused on three things: building up his weight, therapy with his family, and therapy with the patient around gender issues. In addition, a teacher was involved to prevent bullying at school. The boy refused the hormone treatments to induce puberty.

The patient’s weight improved steadily until his size was normal for his age and height, but the therapists thought he might relapse in the future due to family conflict and social prejudice.

In this case what worked was a combination of therapy for both the eating disorder and the gender dysphoria, along with family issues.

As always, it is important to remember that this is a case study of just one person. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

More details on the case:

The boy had been gender non-conforming since he was three and had stated that he wished to be a girl. At age 10 his weight dropped and he was referred to a psychiatrist who diagnosed him with gender identity disorder. He was being bullied at school for being gender non-conforming and developed depression, abdominal pain, and headaches.* He was also dealing with severe conflicts between his parents and an older brother with behavior problems.

At that time, therapists helped him develop coping strategies to deal with the bullying and counseled his parents. His eating, weight, and mood improved quickly.

At age 12, his weight dropped rapidly and he had cold extremities and no signs of puberty. He was living on water biscuits and low calorie orange squash (sweet fruit juice) while exercising up to five hours a day.

He was diagnosed with anorexia “in a context of long-standing eating problems and marital disharmony,” with the doctor’s recommendation of hormones to induce puberty as a “significant precipitant.”

“… he admitted feeling uncertain about hormone treatment. He wanted the comfort of acceptance by his social peer group, but felt happiest and most at ease in a feminine role. After the issue of hormone treatment was raised, B. briefly attempted to control and even deny cross-gender behaviors as if forcing himself to conform to male sex stereotypes. His behaviour soon returned to being highly effeminate. He dressed in female clothing and jewellery whenever he could, wore make-up and stylized his hair into a long pony-tail. His interests were hairdressing, fashion magazines, and knitting. At school he associated only with girls and was physically nauseated at the idea of having to play contact sports like rugby with other boys.”

Treatment included individual therapy related to his gender dysphoria:

“Individual work with B. was difficult because of his high level of denial. Over a period of time he began to focus on his dilemma between social conformity which would allow acceptance by others and his acknowledgement of his own revulsion at the idea of his developing male sexuality. In therapy he recognized that he had attempted to delay puberty by restricting his calorie intake. His anxiety about puberty related to his fear of the development of male secondary sex characteristics, the acquisition of a male sex drive, and potential loss of slimness. He was troubled and confused by homosexual and heterosexual fantasies. Exploration of these themes allowed some gradual resolution. Over a period of several months, he began to see some positive benefits from the eventual development of secondary male sex characteristics and to recognize that these changes did not necessarily preclude the continuance of cross-gender behaviour which was an undeniable part of his identity.”

A teacher at his school was also involved to “provide a contact in school who could help B. with teasing and tactfully educate other staff members about his special needs.”

His weight improved steadily and stabilized at 95 percent expected weight for his age and height.

This is a case history of two Canadian teenagers with severe eating disorders. Both teens had had other psychiatric problems, and in one case the problems were quite severe.

Both teens developed gender dysphoria as time went on. In both cases, they were treated successfully for their disordered eating without being treated for gender dysphoria.

It is not clear exactly what the relationship is between the eating disorders and the gender dysphoria in these two cases.

It is important to remember that this is a case study of two people. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

Case 1

The first patient identified as a very feminine gay male when he entered therapy. He was out to his friends and family and they were accepting of his sexual orientation. He was in a monogamous gay relationship.

The patient was 16 and for the past three years he had had “vomiting, food restriction, and body image distortion, perceiving his body to be overweight.” These problems became so severe that he was admitted to a hospital program.

He had insomnia, depression, problems concentrating, and a low energy level. In the past he had been diagnosed with anxiety. He had cut himself in middle school. His family’s history included substance abuse, depression, and bipolar disorder.

The patient had had body image issues since he was six. He “wanted to stay small, feminine, petite, lean, and thin. He reported that he also disliked his ‘wide torso and broad shoulders’ and wished his face shape was more round to be more in keeping with a feminine ideal.”

However, he did not wish to transition to be a woman. He did not want to physically be a female and was not upset about being a male. Rather he wanted to appear feminine and “assume the female role in a relationship.”*

After his hospital stay, the patient entered an out-patient therapy program that “focused on body and self-acceptance, along with enhancing self-efficacy. The family was involved in order to support his eating, and to accept his sexuality and gender identity.”

With this support “he was able to maintain his weight and left his relationship with his male partner who was emotionally abusive.”

Then, after about a year of treatment, the patient said he wanted to transition to living as a female. He did not want surgery, just blockers and hormones. At that point he had already regained a healthy weight and was not restricting his food. He was referred to a gender transition clinic at his request.

Because he was turning 18, his treatment at the pediatric eating disorder clinic ended.**

Case 2

The second patient was a 13 year old girl with a past history of obsessive-compulsive disorder (OCD), generalized anxiety disorder, and post-traumatic stress disorder from sexual abuse by her father. She had also self-harmed and considered suicide. Her family’s history included depression.

At the time she came to the clinic she had anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). She was taking fluoxetine and olanzapine.

She had been hospitalized twice before for her eating disorder and had a “two year history of food restriction, a rigid eating schedule, and body image preoccupation…She described becoming distressed after eating foods she considered were unhealthy, which prompted her to forgo these foods entirely. She also reported excessive exercise due to a desire to be muscular.”

The patient refused therapy, but came in for medical visits and to see the psychiatrist. She had trouble eating more, so they asked her mother to help, but after six months the mother suggested residential treatment and the daughter agreed. The patient’s fluoxetine dose was increased.

The patient began to talk about wanting to be a boy. She also thought that sex was gross. She wanted to stay at a low weight in order to prevent breast growth and menstruation. Therapists raised the question of her trauma and how it might affect her feelings, but she did not want to discuss it.

“Mother was not accepting of the patient’s desire to be a boy and therapy with the psychiatrist was focused on mother taking a more neutral stance.”

After a year, and after she had been fully weight-restored for several months, she began to dress as a boy and use a boy’s name. She hated her breasts and sometimes hit them or thought about cutting out the fat, but she did not want to have surgery. She said that she no longer had eating problems, her only problem was wanting to be a boy. She wanted to take puberty blockers. Her mother was not in agreement and the girl dropped out of treatment.

Gender dysphoria and eating disorders in these case studies

It is difficult to figure out what these case studies mean. Rather than gender dysphoria causing an eating disorder, these patients seem to have developed gender dysphoria over time while recovering from eating disorders.

The authors suggest that as the patients regained weight, their bodies changed and this made the gender dysphoria intensify. I find this unconvincing.

In the first case, the patient was concerned about his wide shoulders and angular face; gaining weight would not have changed his shoulders or made his face more angular.

More importantly, the patient was clear at the beginning of treatment that he was a man and was not distressed by being male. Saying that he wanted to transition to a female but not have surgery was not a question of symptoms intensifying or becoming more prominent. It was a dramatic change – he went from not having gender dysphoria to having it.

In the second case, it seems likely that surviving childhood sexual abuse caused the patient’s disgust with sex and hatred of her breasts, as well as her depression, anxiety, and habit of spraying her body with Lysol.*** Both the eating disorder and the gender dysphoria could be interpreted as ways of dealing with these feelings.

Why or how exactly the patients developed gender dysphoria during this time is unclear. This question is an important area for future research.

The relationship between gender dysphoria and eating disorders is unclear in these two cases, but it looks like the eating disorders were not caused by the gender dysphoria. In the first case, the patient had the distorted perception that he was overweight; this is a symptom of anorexia rather than gender dysphoria. In the second case, the patient had been sexually abused as a child and had many psychiatric disorders, including OCD. Her eating disorder could be explained by a combination of trauma and genetic factors.

What is clear is that in these two cases, the patients were successfully treated for eating disorders before any gender issues were addressed.

Stay tuned for more case histories related to eating disorders and gender dysphoria.

** I can’t figure out the math here. He was 16, but after 11 months he said he wanted to be a girl. Then they say he left their program because he was turning 18 and had been having therapy continuously for 18 months.

*** No doubt there were genetic and hormonal factors as well, but I think it’s fair to point to the abuse as a cause.

We need more studies to find out how common this is for children with autism and gender dysphoria.

In addition, we need studies to look at how persistence and desistence from gender dysphoria work for children with autism. Is the developmental process different from neurotypical children? How should parents, educators, and therapists work with children who have both autism and gender dsyphoria?

As the authors say, “Careful long-term clinical observation and further studies are needed.”

More details on the boy’s gender dysphoria:

[The boy came to the clinic at age 5 for behaviors related to autism] At the age of 7, he verbalized a strong aversion to being a boy and desired to be a girl. The boy behaved as if he were a girl and preferred to play with girls. Based on his clinical symptoms that lasted more than 6 months, the comorbid diagnosis of GID was made according to ICD-10 criteria.

After entering school, he exhibited behaviors such as using stationery with Disney princesses and dressing himself in clothes with flowers. He rarely went to the bathroom because he did not want to be seen urinating in a standing position. He skipped swimming classes at school to avoid exposing his chest. Only at his home, the boy wore skirts and makeup. At school, he was bullied by classmates because of his feminine behaviors. However, as school teachers were supportive and intervened appropriately, he never refused to attend school.*”

“At the age of 11, when puberty started, he became confused and repeatedly shaved his body hair. He tried to keep his voice tone high. However, as puberty progressed his gender dysphoria gradually alleviated.

In Japan, in general, junior high school students are required to wear school uniforms based on their biological sex, typically a skirt for girls and trousers for boys. They are also requested to obey school regulations related to length of hair, though the strictness is highly school-dependent. Our patient entered a public school in his residential district and had to behave as a typical male student. As a consequence, his gender-related manifestations fell below the threshold for the diagnosis of GID as of age 16 (the time of this writing).”

Note: This is not just a question of changes in behavior – the authors also say that his gender dysphoria gradually alleviated as he went through puberty. In addition, the authors got informed written consent before publishing this study.

*School refusal is a significant problem for students with gender dysphoria in Japan. (Bullying seems to be a problem everywhere.)

This is a case report of two Turkish boys with autism and gender dysphoria. Unlike this earlier study of two boys with autism, the boys in this study verbalized a clear desire to be a girl.

In the earlier case study, the boys had cross-gender interests, but probably did not have gender dysphoria. In this case study, however, the boys had cross-gender interests and gender dysphoria.

This study followed the boys for at least four years, so we know that the gender dysphoria was not transient.

We do not, however, know if their gender dypshoria will persist. Most children with gender dysphoria desist around the time of puberty. What happens with children with autism? Are they more or less likely to persist in their gender dysphoria? How should parents and educators handle their gender dysphoria? Is their gender dysphoria different from gender dysphoria in neurotypical children? How common is gender dysphoria among children with autism?

In the first of these two cases the patient was treated with behavior modification, encouraging separation from the mother, and establishing a bond with his father. His cross-gender behavior continued. In the second case his parents tried to establish a good bond with his father, but again, his cross-gender behaviors have continued.

The author of this study suggests that gender dyshoria in children with autism may be underreported and might be interpreted as unusual interests rather than actual gender dypshoria. At this point, however, we don’t have enough data to know if that is the case. This is a case study of only two children.

This case study does, however, show that children with autism can have genuine gender dypshoria, like the Swedish teenage girl in this case study and the Japanese boy in this one.

“This case study, which is a preliminary attempt to report the developmental pattern of cross-gender behaviour in autistic children, tries to underline that (1) diagnosis of GID in autistic individuals with a long follow-up seems possible; and (2) high functioning verbally able autistic individuals can express their gender preferences as well as other personal preferences.

Finally, this report points to the need for further study of gender identity development as well as other identity problems in individuals with high functioning autism.”

“One year after the referral [for autism], when he was aged 6 years, he started to show improvements in spontaneous speech and imitative play, and displayed more interest in his peers and other people. At the same time, his mother reported some cross-gender behaviours such as wearing his mother’s dresses, putting lego bricks in his socks under his heels and pretending to have high-heel shoes. Along with the improvement in spontaneous speech and imitative behaviour, he started to state his disappointment about his gender. Sometimes, he prayed and begged God to make his penis disappear. After these verbal expressions, he shared his fantasy about his wish to become a bride, married to a man from the age of 8 years. He never shows interest in male activities, he always avoids rough-and-tumble play and prefers to play with girls. Although he has shown some improvement in his social relatedness and language, his social difficulties in terms of reciprocal relationships with peers and sustaining a conversation with others still remain. Despite the eclectic treatment approaches (behavioural modification, encouraging separation from his mother and establishing a bond between him and his father), his cross-gender behaviours show a persistent pattern.”

Case 2 – 7 year old boy with autism:

He started to use phrases at age 4 years [he was referred to the clinic at age 3 for autism], showed improvement in social relationships and sharing interests with peers at nursery school. He also started some make-believe play. At the same time, he had shown persistent attachment to his mother’s and some significant female relative’s clothes and especially liked to make skirts out of their scarves. After age 5 years, he started to ‘play house’ and ‘play mother roles’. This was the most persistent and most pervasive pattern of his play, and he pushed his therapist as well as his peers and family members to ‘play house’ with him. He avoids rough-and-tumble play and likes to share his interests with one or two of his female classmates. His parents were worried about his behaviour and tried to prevent it, but he reacted aggressively. He started to state his desire to grow up as a woman (like his mother). He gave up his attachment to some feminine objects, but still shows persistence in playing the ‘mother roles’ and expresses his desire to be a woman. Although there are some improvements in terms of social relatedness, language and the disappearance of stereotypical behaviours, his social interaction pattern is still inappropriate for his age. His parents have tried to establish good bonding between him with his father as a identification object. Despite this, his cross-gender behaviours are persistent.